Friday, April 4, 2008

For many untreated alcoholics, there may be an alternative to staying in a specialized facility for weeks.

The proposed alternative is the family doctor.

New research says the primary care physician's office can become the new base for alcoholism treatment.

Doctors can prescribe new drugs that help alcoholics start treatment and stay sober, refer them for outpatient behavioral therapy and also direct them to local support groups -- never requiring a stay in a residential rehab facility, according to an article published last December in the Journal of the American Medical Association .

Jim Cowser, a chemical dependency therapist in the Center for Behavioral Health at Baptist Hospital East, thinks it is a treatment model that is long overdue for some people who abuse alcohol. For example, "women who are single parents can't just leave for a month to go to an alcoholism facility," he said.

Some people who are abusing alcohol also face employment issues or lack insurance that covers a residential facility, Cowser noted.

New drugs are a big part of the reason for the shift to more office-based treatment, according to the JAMA article. In April 2006, the Food and Drug Administration approved an injectable form of the drug naltrexone, which curbs alcohol cravings. An injection lasts for a month, greatly aiding patients who use it on their journey to abstinence. The same drug in the oral form has to be taken daily, and it's easy for a patient to skip pills and start drinking.

"If they are planning a bender, they can stop taking their oral naltrexone on Thursday and be able to feel the effects of alcohol again on Friday," Cowser said.

Naltrexone blocks opioid receptors involved in the rewarding effects of drinking alcohol and the craving for alcohol after establishing abstinence. It has been shown to reduce relapse among heavy drinkers. It also has been shown to benefit patients with a family history of alcohol problems.

Another drug in the family physician's arsenal is acamprosate, which is used when patients have been abstinent, not while they are still drinking, or it may not work. It affects the biochemical systems involved in alcohol dependence.

Acamprosate is taken several times a day, said Dr. Billy O. Barclay, a Louisville psychiatrist who treats patients at University Hospital and the Norton Psychiatric Center. He said taking pills that often can represent a challenge for some patients, while others use the act of taking their pills as a frequent reminder that they are trying to stay sober.

There is also disulfiram, a long-available drug for treating alcoholics. It interferes with the activity of the liver enzyme that processes and metabolizes alcohol. A person on disulfiram becomes ill if alcohol is consumed.Off-label uses

Physicians are also turning to topiramate, an anti-convulsive drug, which has not been approved by the FDA for treating alcoholism, but is being prescribed off label to help alcoholics stay sober.

"I think the fact that this medication is being looked at in this way is good. It's going to lead to better things and the use of drugs (for treating alcoholism) that doctors in general are used to."

For now, topiramate is out of reach for many patients, Barclay said, because it is expensive, and insurance often doesn't pay for it.

Cowser and Barclay both said that some patients who suffer with alcohol dependency regard taking any medication as another form of dependence on chemicals and refuse.

"People have all kinds of attitudes that prevent the use of these medications," Barclay said.

"They feel the only solution is abstinence and have a sense that to take anything is a crutch or cop-out," Cowser reported.

He said the use of medications need not be long-term. "I have worked with people who stopped the medication after a few months and did well. Some have used them for a year or two. They are usually not taken for the rest of your life," he said.

After abstaining from alcohol, it takes the brain a year or two to recover, Cowser noted.

Barclay said the role a primary care physician plays in helping a patient fight alcoholism may depend on the physician's interest in the problem.

"Some are gun-shy about it and quickly refer a patient to a specialist. Some have more experience and interest in it and might do a nice job of it," he said.

"There are studies that show that even brief interventions about smoking by a family doctor make a difference," Barclay said. Perhaps that would prove to be true of family-doctor interventions with the addiction to alcohol as well, he suggested.Doctors step up

"I'm seeing a lot more confidence on the part of family doctors," Cowser said. "There is a very promising swing. A lot of people who have had a barrier to getting help with their alcohol problems are now able to start with their family doctor."

Dr. Mark Willenbring, director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism, recommends that physicians consult the NIAAA's recently updated "Helping Patients Who Drink Too Much: A Clinician's Guide."